Tuesday, June 20, 2006

Statistics Difficult To Obtain On Gambling Addiction

In a previous article I wrote about a woman who took her life due to her gambling addiction. The family decided to tell people it was due to personal problems she was having adjusting to living in the United States. She had moved there in June of 1998. Everyone accepted the explanation with out commenting. This is very typical behavior which leads to bad statistical information being presented by local governments.

Gambling addiction is a silent killer that strikes innocent people when they least expect it. It only creates a world of misery with a self destructive behavior. Compulsive gamblers are able to beat their addiction if they have the proper resources.

If governments can not get the true statistics they will never be forced to deal with this addiction. They will continue to raise needed taxes from the gambling establishments. What the government never realized or refused to say is that if their state’s business industry began to thrive the taxes levied against them would be equal to or greater then the amount of revenue generated from the gambling establishments and the state’s lotto.

The government looks for the easiest way out verses taking the time to put a good plan into motion. It’s political suicide to face this addiction head on.

I find it ironic that a new governor will take the time to tell its people that over the next four years we are going to boost our economy and reduce unemployment. There are so many promises made that are not kept that people have lost respect for their political leaders. Those who have been negatively affected by gambling know the truth and need to come forward in order to help others who are living similar lives.

I would like to see one political leader step up and admit their state has a gambling problem. It’s easy to see that doing something like this may cause them to lose their next election. Unfortunately there is no quick fix. Another reason political leaders are afraid to come forward is due to the gambling establishments are run by very powerful people.

When you here rumors that the governor is spending the weekend with the chief of one of the local casinos and a week later the casinos request for expansion is approved. You have to start questioning the motives. How is the state benefiting from this expansion? Do political people only march to those who pay the piper? Is this rumor true or false? Does it matter? Do I care? Does anyone care? I have found people do care but are not willing to get involved. This type of thinking becomes evident after you have a Governor of Connecticut jailed, mayors in multiple towns jailed and other minor infractions by political candidates. All do to pure greed.

Once people decide they have had enough and only then can change occur. Once this change happens, recording of gambling addiction statistics information will improve and governments will be forced to face reality. Then you will see change and people will begin to heal.

Mr. Howard Keith has an extensive background in dealing with compulsive gamblers, relatives and friends of gamblers and teenage gamblers. Mr. Keith believes there are many alternatives to aid in the recovery of a gambling addiction verses a twelve step program. A large percentage of his emails were from compulsive gamblers looking for an alternative to Gamblers Anonymous and twelve step programs. Gamblers Anonymous also helps a significant number of people each year but there is a large percentage that they are unable to reach.

For more information on gambling addiction and stop gambling you can check out I Stopped Gambling So Can You http://www.istoppedgambling.com/

Friday, September 30, 2005

IV Drug Abuse: Inside the Clinic

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IV Drug Abuse: Inside the Clinic

Provided by Psychology Today

PT listens as patients discuss addiction, AIDS and the promise of a new life without drugs

Harlem Hospital Center

Harlem Hospital Center occupies an architecturally diverse compound on 135th Street and Lenox Avenue in New York City. Although sizable, the 720 bed hospital is virtually alone in serving the medical needs of a community of approximately 500,000. And this is no ordinary community. Since the mid-1980s, the drug problem in its streets and tenements-always a powder keg for health and public safety-has grown geometrically worse. The well-documented crack epidemic has exhausted police, social services and health workers, but it's consequences are many, and not immediately obvious.

Some months after crack first appeared in New York nearly 10 years ago, police began to see a huge rise in the number of heroin arrests. Addicts would often turn to heroin, an opiate comparatively out of favor in Harlem since its hey-day in the mid-'70s, to ease the horrific edges of a crack binge. Dirty needles were shared for the injections among many users in the condemned houses and abandoned lots littering the East Side. As a result, the HIV virus, which causes AIDS (also a newcomer to the inner-city in the early '80s), was given an ideal environment in which to spread.

An already badly outnumbered and overworked staff at Harlem Hospital Center was soon forced to revamp their substance abuse program when a random sampling of heroin and crack addicts revealed an alarmingly high incidence of HIV infection. Suddenly, the clinics had to cope not only with the users who sought treatment, but also with the wives, husbands, lovers, and children of these users who were infected by HIV in the womb or through sexual contact.

Dr. James Curtis, director of psychiatry at the hospital, directs the operation of the four IV-drug-use clinics in Manhattan. "Without intervention," Dr. Curtis says, "any addict told that he is infected with HIV may well become desperate and possibly go on even more destructive binges, affecting his loved ones and their loved ones in turn. The clinics are very much on the front lines. We very often must deal with those who have simply run out of resources to live a life on drugs, and by that time, they're lucky if they can make it here given their mental and physical state."

It is Dr. Curtis's and the clinical staff's precarious responsibility to offer counseling to these people, to establish their medical condition and convince them that life without heroin is better, even in the face of a deadly disease for which there is currently no cure.

PSYCHOLOGY TODAY received special permission by Harlem Hospital's directors to attend this group-therapy session. The following is a direct account of remarks offered by patients of the IV-drug-treatment program conducted by Dr. Curtis's associates, Dr. Michael Scimeca and Dr. Gopal Ram. The names of the patients are fictitious.

"I was told three years ago that I was HIV positive," said Mary, a forty-year-old mother of three daughters, ages 2 to 12. Last January, Mary began to show the first signs that her immune system was rapidly breaking down. Ordinary colds would last weeks ... then months. During the fall, her T-cell count, a prime indicator of her body's ability to fight infection, had plummeted from a relatively normal level of 1100 to below 200. Her youngest was born with AIDS in 1991.

"I'm scared all the time, but not of getting sick. I live with feeling sick. Being sick is as much a part of me as my arms and legs now. I'm scared for my family. When I have to go to the hospital, what will my daughters do? I don't have no insurance to help them, not to mention the medical costs of having me on my back. I know that they will line me up and say that I'm just another dope fiend or crack head. And I'm not. I've been straight for seven years now."

"What makes you think that you'll be treated so badly?" asked Dr. Ram.

"Now come on. Someone walking into a hospital with no money is going to die from AIDS one hell of a lot quicker than someone with a big check book. When I delivered my baby, I nearly died in the emergency room before I could get close to a doctor."

"I don't know how to reassure you about that," said Dr. Ram. "I cannot speak for those who delivered your baby, but we certainly do what we can in the facility at Harlem. I'd be lying to you, though, if I denied that communities have only so many resources to help people with, and in many ways, doctors are as puzzled about AIDS as you are. But it is similar to all other diseases in that how you act and how well you take care of yourself has a tremendous impact."

"How many of you here are HIV positive?" asked Dr. Scimeca.

Nine of the 12 members of the session raised their hands.

"I know that some of you are taking medication. We have been distributing AZT from this clinic for years now. Do you think that the medicine has helped?"

"I can't sleep at all since I tried it," offered a woman staring into her folded arms. "I can't get no one to help me get to sleep. And you know I've been to see you about this before Dr. Ram."

"Helen, I know you can't get to sleep, and you know that we have been trying different ways of helping," Dr. Ram replied. "AZT has a different effect on each patient, but I think your sleeplessness has more to do with your being depressed than with the medicine you're taking."

"To hell with that. And why shouldn't I be depressed?" Helen began to raise her voice. "There ain't no professionalism here. Where am I supposed to go..."

"What happens when you try to sleep?" asked a man to her left.

"I get these attacks. I feel my head pounding. Something hammering away. I sweat and shake all over till the whole bed's movin'. I just have to get up ... have to get out." She began to cry softly. "I'd give anything to be able to shut my eyes."

"The group is one of the best ways for people, especially people with little or no other emotional support, to cope with this entirely new life," Dr. Curtis reports. "One important thing to realize is that these people have spent a life of secrecy. Their abuse of drugs, usually more than one at a time, is almost always a shadowy affair, kept hidden from friends and family until the abuser's life simply disintegrates from the strain. Yet the secrecy continues even after family and friends are no longer there.

"The introduction of AIDS into the community made secret drug use even more deadly than it was previously. We try to convince newcomers that it is imperative to be tested, not only for them but for their partners. Additionally, we encourage all to discuss their HIV status within the group. Of course, this means breaking the powerful silence and ignorance which has ruled many of their lives. It comes slowly."

"AZT scares the hell out of me," said a man in his late twenties sitting off to the side. "Between the methadone to kick the heroin habit and AZT, life's a joke. I can't hardly gather the strength to get up in the morning. I can't taste my food, or smell, and my body hurts so much that I just want to forget the whole damn thing and give it up."

Many in the group looked up from the floor at the mention of this and nodded in agreement. "I mean, how sick do you have to be to get well?"

"I've been medicating myself since I was thirteen," interrupted Helen, an ageless woman with powerful shoulders that poked from her sweater. "I made more mistakes than I was due. Now I've got AIDS and I'm gonna die. Why should I go on medicating myself with AZT until it's all over. I'm no addict anymore. To me, drugs are just another way of keeping me quiet. Always have been. I don't want those last few years if I just go on sleeping for fourteen hours a day and feelin' like sleeping for the other ten."

"I can't sit here and tell you that AZT will be your miracle drug," said Dr. Scimeca. "One of the things you've got to face is that this medicine is a matter of risks and benefits. AZT helps to stave off the infection, but it has some nasty side effects. You have to decide what is going to help the most. No one's going to make you take it, and in some instances, it only helps to a marginal extent. But without it, I know the chances of you just ... deteriorating are considerably better. It's a matter of weighing your fears as much as anything else."

"Fears! HIV is the only thing that ever scared me in my whole life," said Jane. "I never have found a way to deal with it. I've been toughing it out with men my whole life. Ain't none of them ever scared me. My father, my husband ... they were burning up with anger their whole lives. They beat me, twisted me around, and then they just died. But they were simple. I knew how to beat 'em. AIDS is a woman to me. It's trying to fight something inside. Where do I start?"

"Jane, how long have you been straight?" asked Dr. Ram.

"Fourteen years."

"How many people do you know who were addicts fourteen years ago are alive today? Not a whole lot I'd imagine. By accomplishing that, you are a success story. You already have resources to fight."

"There are some things that you can't fight against, though," offered a man sitting near the doorway. "I'm an ex-police officer, ex-drug addict, and ex-con. Like everyone else here, I've done wrong to myself and my family. I've seen drug issues from all perspectives, and after I got clean, I thought I could make a difference as a drug counselor at school. When I began speaking to kids, I started to feel important for the first time in my life, as if all the shit I'd gone through meant something. But I was let go a couple of weeks after my boss found out about me being positive. Now here I am. I may not even be sick for ten years but I can't get a job. I'm branded as something that no one can even get close to, much less give a job to."

"It's true", said Mary. "Friends I'd had for ten years just about left town when they found out. And I can see now what they were thinking. I mean, my God, what with HIV, tuberculosis and everything else, it's a wonder people open the door in the mornin'."

"But Mary, you're talking about HIV as if you can give it to someone at work if you look at them funny," said Earnest. "I got it from sticking needles in my arms, and no one who ain't an addict has to sweat over catchin' it that way. To me, AIDS is just another reason for prejudice. That's all. It doesn't matter if you've been off drugs thirty years. To the world, you're still a junkie. And if you have HIV, no matter how or why, you're just a germ and that's reason enough to hate you."

"So what if that's true? I've been living with prejudice all my life," said Janice, a heaviset woman from the back row. It was the first time she had spoken during the session. "It's still just hate. And your choice is the same. You either let it get you or you don't. And believe me, feelin' hate all the time ain't going to make you feel much better when the time comes to be sick or not. This is my family," she gestured to two young women just behind her. "I'm lucky to have them. When I don't have the guts to fight, they do it for me."

"I watch my baby getting sicker every day," said Mary, staring into a cup of coffee. "I wake up every day knowing that I didn't just mess up my life, but that I poisoned my baby. I cry every day for her, and I want to give up half the time, but I have two other girls to think about. Now if I can deal with that, you can deal with findin' a job."

"Yeah. You do have a family," said Earnest. "But what if you don't. What the hell are you supposed to do if nobody believes in you. I lost the last of my family three years ago. I have to fight for me now. And who can believe doctors? What does anyone who don't have HIV have to tell me? As if the man behind the desk is going to give a shit if I live or die. It's a paycheck to him, and you're all fools if you don't know that."

"Ernest, none of the staff here are getting rich, believe me," said a nurse standing near the doorway. "If we wanted a fat paycheck, there are other ways..."

"You all go to families at the end of the day though," Ernest spat. "You go home, eat a big dinner, watch TV. I'm here with nothing, do you understand?"

"So you're pissed," said the man next to him. "So what? What do you want the nurse to do, bleed for you? If you're really sitting there waiting for this woman to solve your problems, you're gonna be pissed off till you die. If that's what you want, go ahead, but don't be telling anyone here that they're fools."

"That's real easy. Just go off and figure shit out. No help. No family," Ernest said.

"You find some family then," said Janice. "You stop being hurt all the time and take a look around ... how 'bout at the people in this room. And you know," she smiled, "it seems to me you always left here with something, Earnest."

"Besides the coffee," Mary said.

Figures vary among the four clinics that Dr. Curtis directs, but approximately 60 percent of those who appear at the clinic doors in Harlem are HIV positive. "And we have the facilities to see just a small fraction of those addicts who would accept help," says Dr. Curtis. "At least in the short term, the medical community is perplexed in dealing with HIV. Any hope simply lies in stopping the spread. And distributing information is not enough. A solution will only come from a comprehensive network of social services. It is imperative that these people not be left to die alone, because they won't. Unless we intervene, their families, and others, may well follow."



Originally published by Psychology Today:May/Jun 93









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Trapped in the Web - Internet Addiction

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Trapped in the Web

Provided by Psychology Today

More and more people are discovering the joys of the Internet. But once they arrive, some find it nearly impossible to sign off. Here's what you can do to prevent on-line excursions from taking over your life.

Frustration with the sluggish speed of a browser is the about the most serious psychological pitfall that most of us face when surfing the World Wide Web. But for as many as five million Americans, experts say, the Internet has become a destructive force, its remarkable benefits overshadowed by its potential to disrupt the lives of those who can't resist the lure of round-the-clock social opportunities, entertainment, and information. For such people, work, friends, family, and sleep are replaced by a virtual world of chat rooms and games.

Take Judy and Bob, a Seattle couple who were saving to buy their first house--until monthly credit card bills started arriving with $350 charges for online services. Bob was "pissing away all our money on the Internet," says Judy. And soon he was doing likewise to their marriage. Every evening Bob came home from work and headed straight for the computer, he stopped joining Judy for dinner or helping with household chores. At 10 P.M. each night Judy hit the sack, while Bob stumbled to bed some five hours later. Before long he was sucked into cyberspace 40 or 50 hours a week. When it became clear after six months that Bob had chosen his on-line world over his real one, Judy left.

Such tales became increasingly common in the early 1990s, when the growing popularity of commercial providers made the Internet affordable and accessible to anyone with a personal computer, modem, and phone. Only recently, however, have psychologists begun devising strategies to wean on-line addicts from their endless browsing and chatting. And while it's too soon to say how successful their efforts have been, their hope is that the extent of the problem will be recognized before it becomes even more widespread.

Cybertrouble

One of the first experts to notice the some people were spending an unhealthy amount of time on the Internet was Kimberly Young, Ph.D., an assistant professor of psychology at the University of Pittsburgh, Bradford. In 1994, Young launched the first major study of the problem, surveying nearly 500 avid Internet users about their online habits. Because there was no formal definition for the disorder--which she quickly christened "Internet addiction"--Young classified study participants as "dependent" or "nondependent" Internet users based on their answers to seven questions she adapted from those used to diagnose pathological gambling. (Sample question: Do you experience withdrawal symptoms--depression, agitation, moodiness--when not on-line?) Those who answered "yes" to three or more questions were classified as dependent.

On average, Young found, dependents spent an astonishing 38 hours a week on-line, compared with just five hours a week for nondependents. And usually they were not cruising the information highway to enrich their knowledge of El Nino or the Russian space station. Instead, dependents sought contact with other people: their favorite activities were chat rooms (35 percent) and Multi User Dungeon games (28 percent), while non-dependents were most likely to use the Internet for electronic mail (30 percent) and searching the World Wide Web (25 percent). Similarly, a 1996 survey of 530 college students by Kathy Scherer, Ph.D., a psychologist at the University of Texas at Austin, found that dependents and nondependents spent similar amounts of time exchanging email and searching the Web, but dependents spent twice as much time in chat rooms and playing games.

None of the non-dependents in Young's study reported academic, personal, financial, or occupational problems caused by their Internet use. But about half of dependents reported problems in all of these areas. Yet many dependents insisted they couldn't give up the Internet; a few even tossed out their modems, but their Internet cravings led them to buy a new one to get their cyberspace fix. In fact, the smokers in the study reported that their cravings for the Internet were stronger than the urge to light up a cigarette.

Who's At Risk

Most Internet users don't become addicted. Among people who gamble or drink alcohol, about 5 to 10 percent develop problem behaviors, and Young believes that the figures are similar for pathological Internet behavior. With an estimated 47 million people currently on-line, as many as two to five million could be addicted. Especially vulnerable, Young believes, are those who are lonely, bored, depressed, introverted, lack self esteem, or have a history of addictions.

Perhaps the most surprising--and widely reported--finding in Young's original study was that the majority (60 percent) of dependent users were middle-aged women, particularly housewives, not young male computer geeks. But this has not held up in later studies, which give men a slight edge. Young suspects a bias occurred in her first study, perhaps because women are more likely to admit and talk about their problems. Still, she understands the appeal that chatrooms hold for these women and others in her sample. "You never worry about how you look or how nice a house you have, and you talk to people all over the world. It's instant gratification without having to reveal yourself." Lonely housewives or shy sophomores can feel like exciting people when on-line. "It's novel and unique, and they get attached to the people they meet on-line," Young says.

Indeed, like alcoholics with favorite drinking buddies, Internet addicts form close bonds that fuel their compulsions. Dan, a college student, earned a 3.2 grade point average his freshman year. Then he moved in with roommates who played an interactive Multi User Dungeon computer game as a team from separate computers, and soon began logging on 50 to 60 hours a week. Dan's grade point average nose-dived to 1.6. His fiancee began to complain that he spent too much time with his computer friends; they, in turn, griped when he signed off to spend time with her. Faced with the reality that he might not graduate or get married, Dan tried to cut back, a goal that grew easier after his roommates graduated. A year later, his use was down to 1.0 hours per week. "I still get high on the Internet," he admits, "but I'm in control."

Get high? Internet addiction? Time was when the word "addiction" referred to drug and alcohol problems--period. Today, so-called addictions are everywhere: sex, exercise, work, chocolate, TV, shopping, and now the Internet. Have we been, well, abusing the word?

An Addiction? Really?

"Addiction," notes Young, "is a layman's term, not a clinical one." In fact, the DSM-IV doesn't even mention the word. Young chose the label "Internet addiction" because it's readily understandable by the public. When writing for clinical journals, however, she refers to "pathological Internet use," modeling the term after that for pathological gambling in the DSM-IV.

Other experts shun the term addiction altogether because it means too many things to too many people. "It's a sloppy word," says pharmacologist Carlton Erickson, Ph.D., head of the Addiction Science Research and Education Center at the University of Texas at Austin. In the drug abuse field, he notes, "dependence" has replaced "addiction". "In dependence, people can't stop because they have developed a brain chemistry that does not allow them to stop," explains Erickson. Excessive behavior that hasn't quite reached full-fledged dependency, meanwhile, is called "abuse". If Internet abusers cannot stop for a month, suggests Erickson, then "Internet dependence" would be the appropriate term. Others believe that the problem is best described as a compulsion, suggesting the phrase "compulsive Internet use". And many psychologists question whether excessive Internet use should be pathologized at all: John Grohol, Ph.D., who directs the Web site "Mental Health Net," says that by the same logic, bookworms should be diagnosed with "book addiction disorder".

Perhaps the controversy will be definitively resolved when researchers determine whether behaviors like pathological gambling or Internet addiction produce chemical changes in the brain similar to those found in drug abusers. In the meantime, Young believes that the often severe personal consequences of Internet addiction justify popular use of the term. "Internet addiction does not cause the same physical problems as other addictions," she says, "but the social problems parallel those of established addictions."

Treatments for Internet addiction are beginning to emerge. Trouble is, not all mental health specialists recognize the problem or know how to treat it. Internet dependents have been told by uninformed therapists to simply "turn off the computer." That's like telling a heroin addict to just say no to drugs--and just as unsuccessful. What's more, HMOs and insurance companies do not pay for Internet addiction therapy because it's not recognized by the DSM-IV.

Among those developing treatments for the problem is Maressa Hecht Orzack, Ph.D., a psychologist at Harvard University's McLean Hospital in Belmont, Massachusetts. Orzack founded Harvard's Computer Addiction Services in Fall 1996, after seeing first hand the fallout from Intemet-related problems: divorce, child neglect, job termination, debt, flunking out of school, legal trouble. One client, she says, had separated from his wife but couldn't afford to move out because he spent so much money on computer services. He moved his bed into the computer room and started an affair with an on-line sweetheart.

A cognitive therapist, Orzack likens Internet addiction to such impulse control disorders as pathological gambling and kleptomania. However, "gamblers have a choice to gamble or not," she notes. "People addicted to the Internet often do not have that choice, since so many activities require people to use a computer."

Like Binge-Eating

So the best approach for excessive Internet use, Orzack believes, will be to treat it like binge eating, where the individual frequently engages in the activity to be restricted. She treats both by teaching clients how to set limits, balance activities, and schedule time, without having to go cold turkey. "People often change in six or eight sessions," she says.

Unfortunately, the affflicted rarely admit to the problem, and it usually takes a crisis with a job, relationship, or school to spur an Internet addict to seek treatment. More often, it's loved ones who turn to the experts. "Families notice things and call me," says Orzack. And she receives letters like this: "We got divorced one year after we got the computer. My wife was in chat rooms all the time and ignored our young daughter. She spent hundreds of dollars on phone bills. . . [and] had an affair on-line that turned into a real affair...Then she left. I don't know what to do. Please help." Now lawyers and family courts call Orzack and Young wanting them to testify about Internet addiction in divorce and custody battles. (In October, a Florida woman lost custody of her kids when her ex-husband convinced a judge that the woman was addicted to the Internet and thus incapable of properly caring for their children.)

College students are often vulnerable to Internet addiction because many universities provide free, unlimited access. At the University of Texas Counseling and Mental Health Center at Austin, Scherer and her computer scientist husband Jacob Kornerup created a workshop, called It's 4 A.M. and I Can't--Uh, Won't--Log Off, to help students recognize harmful Internet habits. Scherer and Kornerup recommend keeping a chart sorting weekly Internet time into academic/professional and leisure/personal use. If a large part of your leisure time is spent on the Internet, she says, ask what you get out of it, what you're giving up, and why you're finding on-line time so much more pleasurable than other activities. Take note if your personal relationships are suffering.

Next, set a goal of how many hours a week you want to use the Internet. If your actual usage exceeds it, remind yourself to log off after a period of time. Set a kitchen timer and turn off the computer--no excuses--when it rings.

It's particularly important to separate work and play when on-line, says Jane Morgan Bost, Ph.D., assistant director of the University of Texas Counseling and Mental Health Center. Stay focused, visit only sites needed to complete work, and don't detour. Also, she says, cut back mailing list memberships and sort play e-mail from work e-mail.

None of the experts PT spoke with demonize the Internet; they use it extensively themselves and applaud the benefits of rapid communication and information exchange. But, they add, the Internet is here to stay, and problems with excessive use need to be addressed.


By: Carol Potera
Originally published by Psychology Today:Mar/Apr 98










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What Loving Eyes Can't See

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What Loving Eyes Can't See

Provided by Psychology Today

Their marriage became a bitter embrace when her husband's identical twin killed himself. Tormented by guilt and overcome with despair, Valerie Monroe's husband turned to drugs to ease his pain. Recognizing his self-destructiveness and coming to terms with her own fear of intimacy were Monroe's first steps toward recovering love.

When I first met my husband, he struck me as immensely handsome and immensely shy. I adored him. He used to leave me little notes all over the house. I love you, Angelou. I love you, my ripe tomato. I love you, Val Monroe. I couldn't get enough of him. His quietness, his privateness made me want to open myself to him. I wanted to be the one who brought him into the present, the beacon who guided him back from that dark, silent place he went to.

We had been living together for a couple of years when I decided that Keith and I should be married. I was afraid of getting older--I was over 30--and I knew I wanted a child. I didn't understand that sending the shock of marriage through our relationship wasn't necessarily going to jolt us into anything; it would just jolt us, after which I would slowly sink to the bottom of a sea of ambivalence while holding fast to the heavy weight of my commitment.

Soon after we were married, Keith's silences began to move in on our relationship like a fog. The quality of his quietness seemed to change; when I first met him, I thought I could see behind his silences. Now he seemed to disappear into them. Yet he was untroubled by the shroudlike silence that hung over us night after night.

The problem became particularly acute for me during dinnertime, when I would want to be sharing the events of my day and hearing about his. I resorted to holding up unlined index cards on Popsicle sticks. One evening, after we had sat down to eat and I had begun to feel irritated by the predictable silence from across the table, I held up one of my signs. HOW WAS YOUR DAY? Keith looked over at me. "Cute," he said. More silence. I held up another: PENNY FOR YOUR THOUGHTS. I tried a third one: JESUS IS COMING. Keith continued to eat. Finally, I pulled out the last. THE END IS NEAR. I held it above my head and stared solemnly at my husband.

A year into our marriage, Keith had all but disappeared into his work, or behind the pulverizing pain of the migraine headaches that often felled him and the pills that he took to kill the pain. I didn't know then that migraine pills were not his only problem. He also used cocaine, and in that way he was linked to his twin brother, Brian, as if they shared not only the same genes but the same arc of fate.

The winter our son Reid was born, both my husband and his brother had entered another world. Unknown to each other, the two men were gravitating into a deeper, more dangerous relationship with drugs. Though Brian would drop off the cliff before Keith even saw the end of the road, Keith's and Brian's journeys had each taken a turn along the same treacherous path.

It became increasingly painful to be with Keith. He hardly spoke at all and seemed irritated and restless in the house, like a trapped animal. What still astonishes me is how much I accepted; how badly things had to deteriorate before I finally admitted that something was seriously wrong.

Three years into our marriage, Brian's addiction triumphed. The coroner's report: Jumped in front of truck. Death due to: Suicide.

Losing an identical twin can be more devastating than losing a parent, a sibling, even a child. Within two months of Brian's death, Keith was out of control and spiraling into a crash: on many days no one at his office knew his whereabouts; he was often coming home sometime before dawn too wired to sleep. All that fall he was absent more and more frequently, until he disappeared for days at a time getting high and coming home sick and wasted, unable to talk, unable to eat, hating himself. I didn't know what was wrong. "Talk to me," I said. "Cut out this shit and talk to me!" But he couldn't respond. I was afraid, if he did speak to me, of what I would find out. Keith was getting royally high, and I was the Queen of Denial.

I knew one thing: he wanted to join his brother. He wanted to die. And if that was all he wanted, he would succeed. The Keith I thought I loved had disappeared. Yet for too long, I could not intervene; I sensed that if I did, there would be no going back. Finally, his doctor recommended that he be hospitalized. It was the first of two hospitalizations; upon his release he inevitably returned to cocaine. I became accustomed to feeling angry with him and wore my anger like an old coat; it kept me comfortable against the chill of his abandonment.

It was beyond my understanding then how profoundly Keith's treatment was going to affect me. Group therapy was required by the treatment program; and as a follow-up to rehab, Keith and I participated for two years in an after-care group. I found it excruciating to share my feelings with people I'd never seen before, or listen to their problems. Yet it was in this group that we learned how to fight. It was simple: we never began a sentence with the word "you." Everything had to begin with "I feel." Suddenly our arguments were turning into confessions of feelings we often weren't aware of. "This is a miracle," I said to Keith the first time we ended an argument facing each other with greater understanding.

But the worst was to come. One night, after he seemed to be straight for a while, Keith said he was going downtown to an AA meeting. I had no inkling of his plans; there was nothing in his tone of voice or his look or in the way he waved bye to Reid to indicate that he was on his way to meet his connection. I went to bed alone at midnight, not having heard from him. I woke up at four, still alone. From my bureau I snatched a framed black-and-white photograph of Keith, taken before we were married. "Do me a favor, you shit," I said aloud. "Get it over with."

A surge of fear, hot and electric, nearly lifted me off the couch when the phone rang later that morning. "Hi, it's me."

"Keith, where are you? Are you high?" I sobbed.

"Just don't worry about me, hon," Keith said, and hung up.

I finally conceded that I needed to get myself some help. I would leave Reid with his sitter and go to an Al-Anon meeting. Just to see what it was like.

When he returned a week later, Keith was thin again, pale, almost translucent in a deathly way.

"Are you straight?" I said from the doorway.

"Yes," he said, keeping his eyes on mine. "I'm finished with it."

In the week that he had been away, I had begun to change. In spite of my discomfort with Al-Anon meetings, I had forced myself to go every day. With each meeting I was opening the door a crack more to the unwelcome idea that I, and not only Keith, needed to change. This adjustment of the focus of my attention from Keith's problems to my own had a remarkable effect. Keith, without the unremitting spotlight of my expectations trained mercilessly on him, was becoming just another character fumbling along in the dark, like me. Freed from trying to figure out what was making him unhappy, I began to take a look at what was making me unhappy. I felt as if, for all my life. I had been wearing glasses with the wrong prescription; after slipping on a different pair, every time I turned to examine something new, it came vividly into focus.

One night I had a dream in which I sat between my parents. I leaned toward my father and kissed him, until I began to feel as if I might go into a swoon. Suddenly I felt my mother's presence and I drew away, frightened and then angry.

I woke up the next morning perspiring and disturbed. I began thinking about the relationships I had had. The men all had one thing in common: when I met them, they were all involved with other women. As long as there was another woman in the picture, I could allow myself not to be in a relationship wholeheartedly. I felt both queasy and awed, as if I were staring straight down into the craggy chasm of my neurosis. I felt something else, too. Hope. That morning I phoned a therapist. "I need to see you," I said. "I have some work to do."

In therapy, I allowed myself to experience the feelings for both of my parents that I had shut away in the dark. Each time that I examined a feeling and didn't explode, or die, or get set upon by wild dogs, I began to acquire a fearlessness.

Something in Keith, too, had begun to change. He said, for the first time, "Ill go through hell before I take drugs again." He began to allow himself to experience his pain.

One morning I stood behind Keith at the bathroom sink as he shaved. "This is it," I told him. "I'm stepping into this marriage with both feet. I'm asking you to do the same."

"I'm in," he said.

"Both feet?"

"Both feet."

Because I was uncomfortable with it, all through the years of Keith's recovery I kept the bulk of my anger at him hidden. Then I noticed that whenever I felt that Keith and I were getting close, I found something to get angry at. I said I wanted to be close to him, but now that the opportunity lay before me, I was scared.

Keith was making an effort to make our marriage work, and he was so much more the person I wanted him to be that there was nothing much to hang my anger on. Yet many nights, after we had spent what seemed like a companionable evening, as I was getting ready for bed I would feel irritation pricking me.

For a long time my anger had comforted me; it was steady, predictable. I used it as a substitute for what I really wanted from Keith. I needed to tell him that I was angry, and that I was sorry, too. That I loved him.

Because of the work I continued to do in therapy, all my relationships were different. Once I discarded my need to be second best, I felt at once less afraid and more alive. I continued to go to Al-Anon, and Keith to AA. Still, there was much hard work to do: Keith's depression, now that he was straight, was so unrelenting that I nearly moved out at one point. It took time before we really began to enjoy being with each other and to know the beginnings of genuine trust and intimacy.

When it finally began to happen, it was a surprise. The real thing, I thought to myself one day It doesn't feel evanescent or ephemeral, winding around us like silk, like a breeze, ticklish and exciting; that was what I thought love was. What Keith and I shared--it felt stout, solid, plain, and grand.

All that I had learned from my parents and from our culture about love was really about the illusion of romantic love, not about loving. With Keith, I learned what loving was. I learned to recognize and to accept the exquisite in the ordinary. I learned how to be in a state of loving, instead of being in love or demanding to be loved. Keith's dark side still saddens me. And my anger over our past still flares up, like the rebel pop and spark that suddenly leaps off the embers of a dying fire. But often it's when we've revealed to one another what is least comfortable that we feel closest. I don't wonder anymore why we married. In spite of not understanding that we had a purpose for each other, we had accomplished it. It was painful, but we had learned how it was possible to be happy alone and together.

From In the Weather of the Heart, copyright (C) 1996 by Valerie Monroe, published by arrangement with Doubleday, a division of Bantam Doubleday-Dell Publishing Group, Inc.


By: Valerie Monroe
Originally published by Psychology Today:Sep/Oct 96









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Treatments that Work

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Treatments that Work

Provided by Psychology Today

Because addiction has no solitary cause, the new view toward it demands that single-minded approaches to drug treatment be abandoned. At least four studies, according to William Miller, have found no differences between groups of alcoholics assigned to Alcoholics Anonymous and to no treatment at all. AA simply doesn't work for a lot of people. Consistently negative findings have also come from controlled studies of in-sight-oriented psychotherapies, antipsychotic drugs, confrontational counseling, most forms of aversion therapy, educational lectures, group therapy, psychedelics, and hospitalization.

"A rather remarkable amount of research has been conducted on the effectiveness of several dozen approaches to the treatment of substance abuse," says New Mexico's Miller. But sadly, he says, the chug treatment community has been curiously resistant to using what works. His colleague, Reed Hester, after a review of treatment outcomes from 1980 to 1990, concluded that "despite much more knowledge of what works, treatment for substance abuse hasn't changed much in 40 years."

Plenty of things, however, do appear to work--some simple, some complicated, and some novel. Some samples:

Brief intervention. According to Miller, studies show conclusively that very brief treatment, if designed properly, is highly successful against even moderately severe addictions.

"We found this out the hard way," he recalls. In 1976, in one of his studies of controlled drinking, Miller separated his subjects into two groups. The treatment group got a variety of treatments, including counseling and disulfiram (Antabuse). The control group was given only a brief self-help manual and told to go home, read it, and do their best.

"To our amazement, people in the control group did just as well as the treatment group. We thought we had really messed up the study so we repeated it twice again and got the same results.

"Then we went looking for what was really happening. We gave one group the manual and another group no manual. The manual turned out to be the variable that was the potent treatment. But why? We knew it wasn't the effect of our initial interview with the subjects, or some difference in the patient groups.

"The key was that we had inadvertently motivated the control group and in spite of our expectations, the addicts changed and moderated their drinking. Simply giving them the manual, saying to them that we believed they could help themselves, could handle it, you can do this, was enough."

Since then, Miller and other therapists have refined and modified "motivational interviewing" and brief-intervention therapy. More than 30 studies in 14 countries have affirmed the value of its key components, dubbed FRAMES: Feedback--specific and tailored to the individual, not general; Responsibility--it's up to you, your choice, you are not a helpless victim of a disease; Advice--firm and clear recommendations; Menu--there are different ways to work this out; Empathy--the best therapists have this and are neither pushy nor confrontational, but supportive and warm; and Self-efficacy--you can do it; empowerment.

"Warm turkey." Tapering down and "sobriety sampling" give addicts a chance to kick their habits and help them not give up if they fail.

In the hands of trained therapists, this and other forms of "relapse prevention" teaches addicts skills for coping with mistakes and setbacks. These methods also allow for moderate continuation of some addictions for some people, rather than insisting on total abstinence.

Pharmacologic treatment. Drug treatments for addictions have historically been the least successful and the least available. Except for methadone (which many experts feel largely failed because accompanying social services and counseling were not given to addicts) and Antabuse for alcoholics, there has not been much to offer.

However, several groups of scientists are conducting studies looking for a methadone-style treatment for cocaine addiction. Now that neurobiologists and neurochemists have pinpointed those parts of the brain and the neurotransmitter system where cocaine exerts its effect, they plan to develop drugs that block it.

As Childers explains: "Cocaine activates dopamine by inhibiting a mechanism that pushes dopamine back into nerve endings that release it. This pump, known as a dopamine transporter protein, is so inhibited by cocaine that dopamine is released in relatively huge amounts."

In the past 18 months, George Uhl, M.D., Ph.D., of the NIDA Addiction Research Center, and other scientists, using the gene cloned for the dopamine transporter protein, located specific areas where dopamine and cocaine both act in the brain.

Childers says the goal is to develop "designer drugs," man-made molecules that can block cocaine receptors without shutting down the dopamine transport system. (These are known as "antagonists" because they block the receptors.) Another strategy is to develop drugs that bind lightly to cocaine receptors, producing a very mild form of cocaine "rush" but also blocking cocaine itself. These drugs are known as mixed agonist/antagonists, or long-acting agonists.

Theoretically, says Childers, such drugs would break the behavioral-chemical links, the cycle that keeps cocaine addicts craving the drug. "We so far have only a long-acting agonist. That would still help clinically, the way methadone does, and those addicted to cocaine binges or overdoses would be helped. It might give a hard-core crack addict a way to come off his high slowly and perhaps not have the terrible withdrawal and craving."

Another pharmacologic approach that is drawing interest and controversy is the African hallucinogen ibogaine, made from the shrub Tabernanthe iboga, which grows in Gabon. Anecdotal evidence and a few animal studies suggest that ibogaine can cure opiate addictions. It's banned in the U.S., but a white powder made from it is available in Holland and many American junkies have gone abroad to get it.

Some patients claim it not only stops cravings for long periods without withdrawal, but also suppresses all desire for any drugs and generates an emotional confrontation with their own thoughts and feelings, during which they are inspired to reorganize their lives.

Scientists at NIDA say there is no evidence that it works, even over the long haul. Studies at Johns Hopkins have shown that ibogaine interrupts dopamine release and stimulates other neurotransmitters.

Still, most experts say the long-term effects reported by some users probably have more to do with the desire addicts have to kick their habits and to their expectation that it will work. At Johns Hopkins, Mark Molliver, M.D., and his team have also found ibogaine kills brain cells in a part of the brain--the orbital frontal cortex--linked to obsessive behavior. At present, neuroscientists at the University of Miami have the go-ahead to test ibogaine at low doses for safety, but not yet on addicts.

Transformational psychology. The new view of addiction and some new ideas about treatment have been fed from such unusual sources as religion, philosophy, and literature. Recent research conducted on abrupt personality change is a case in point. The investigators, William Miller and Catherine Baca, M.D., of the University of New Mexico's Center on Alcoholism, Substance Abuse and Addictions, credit their study of Joan of Arc, Malcolm X, Alcoholics Anonymous cofounder Bill Wilson, Saint Paul, Buddha, Kierkegaard, and Dicken's A Christmas Carol for suggesting means by which some addicts might kick their habits overnight--much the way Ebenezer Scrooge went from wretched skinflint to kindly benefactor after a bad dream.

Whether or not their "transformational psychology" research translates into a practical treatment for addictive behavior, its publication this year by the American Psychological Association and presentation at international drug and alcohol research conferences reflect a shift in thinking about how people become addicted and how they might get free. Until now, says Miller, behavioral scientists have stuck to the conviction that real change, if it happens at all, is gradual and painstaking. Now, says Miller, we know that "relatively sudden and profound changes can and do occur, at least occasionally." If that capability could be harnessed, the impact on addiction could be profound.

Aversion therapy. Toni Farrenkopf uses aversion conditioning to treat addictions, particularly those involving gambling and sexual behavior. He's worked with patients for whom a single incident of voyeurism, or indecent exposure, sometimes at a very early age, was so arousing that the addiction held for decades.

"What we've learned is that people who are voyeurs and exposers are addicted to the rush they get from contemplating, planning, and doing the behavior, not necessarily from sexual release itself. With pedophiles, other factors drive the addiction. But in all cases, you want to try and countercondition the behavior."

Aversive therapy works by introducing negative consequences immediately after the pleasurable experience occurs. One reason that many people don't become addicted is that they rarely experience the worst consequences of their behavior soon enough to override the pleasure.

Farrenkopf uses covert sensitization with imagery. He'll show a sexual addict arrest scenarios--being handcuffed, jailed, searched--10 seconds after an erotic exposure and do this repeatedly. Or he'll expose them to a noxious odor or painfully snap a rubber band on a wrist. "I help the patients experience all of the painful things that happen when they are caught, or have to confront their families after getting caught," he says. "It works for many."

In a related therapy for gamblers and others "addicted to thrills," Farrenkopf makes them do an inventory of how people are hurt by their behavior, and visualize how their family would feel if they were killed or maimed, how humiliating it would be for a professional to be arrested for drunk driving.

Behavioral shaping. A recent study by NIDA researcher Kenzie Preston, Ph.D., uses this method to ease inner-city cocaine addicts off the drug; they get increasing rewards in the form of redeemable vouchers to encourage abstinence. At the end of his first 12-week trial, nearly half the subjects had stayed free of coke for at least seven weeks. Among the rewards purchased with the vouchers: tennis shoes, tires, clothing, and a lawyer's fee.


Originally published by Psychology Today:Sep/Oct 94











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Inside the Addict's Brain

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Inside the Addict's Brain

Provided by Psychology Today

Many details have recently been worked out describing events in any brain exposed to the most common addictive drugs: heroin, morphine, barbiturates, tranquilizers, and alcohol (all depressants that slow down processes in the brain and central nervous system); and cocaine, amphetamines, nicotine, and marijuana (all stimulants that generally excite them).

As the target organ of addiction, brain cells react to stimuli, including substances introduced from outside and hormones and chemicals we make ourselves. Those reactions lead to other chemical reactions and to changes in movement, thought, feelings, and memory. Drugs of abuse abet, or interfere with the chemical messengers, or neurotransmitters. The neurotransmitters that facilitate addiction are released by the 10 billion neurons that deal with information transfer.

Neurotransmitters circulate, collect, and act at specific sites on nearby cell surfaces called receptor proteins, each of which is shaped to fit and receive a particular neurotransmitter and bind it the way a lock "recognizes" a key. Only after a neurotransmitter binds can the signal it carries travel to the next cell. If the cell is flooded with too much neurotransmitter, an elegant "control" system is normally activated so that the cell reabsorbs the excess for later use. This process, called "reuptake," prevents too many chemical signals from circulating and filling too many receptors, which can lead to over-activity and serious mental and physical problems.

Neuroscientists now know that some abused substances block reabsorption, leaving too much neurotransmitter around. Others block the release of neurotransmitters. Although many neurotransmitters and chemicals that act like them have been identified, those most notably linked to addiction are norepinephrine, dopamine, serotonin, substance P, and gamma-aminobutyric add (GABA).

In 1973, Solomon Snyder, M.D., director of neuroscience at Johns Hopkins, and his then-graduate student Candace Pert, put a solid foundation under the new theory of addiction by finding receptors for opium in the brain. They accomplished this by tracking molecules of the drug with radioactive tags to their binding sites. Derivatives of heroin and morphine bind to those same sites. Methadone, a weak synthetic opiate, binds less tightly; one reason it satisfies an addict's craving is that it is addictive but does not produce a "high."

But Snyder and Pert also understood that their discovery had far greater implications. For if the brain had opiate receptors, it surely wasn't because nature intended man to fall victim to heroin addiction, but because the body itself must produce opiates. The discovery in 1975 of the brain's own opiates, called endorphins or enkephalins, demonstrated neurochemical sites of pleasure in the brain activated naturally by human activity.

Soon, scientists would learn that opiates keep opiate receptors constantly full, producing the physical tolerance so characteristic of heroin addiction. They discovered that the opiate-addicted brain also appears to close off some receptors so that desensitization occurs, encouraging larger and larger doses.

They found that cocaine affects nerve cells in the limbic system, the most ancient part of the brain and one closely tied to emotions. But rather than bind to a receptor, it interrupts the process of reuptake that terminates the action of dopamine. Cocaine is not only a blocker of dopamine uptake but of the reuptake of serotonin and norepinephrine as well.

All of this leads to vast overstimulation of nerve cells and creates intense feelings of excitement and joy. With cocaine, dopamine spills forth and floods our pleasure receptors. On the downside, cocaine eventually wipes out the brain's existing supply of these neurotransmitters temporarily, leading to a hellish withdrawal marked by severe depression, paranoia, intense irritability, and craving.

According to Steven Childers, psychedelic drugs of abuse such as LSD and "mushrooms" don't activate the ancient reward system regulated by dopamine, serotonin, and norepinephrine. Moreover, they appear to influence different parts of the brain involved in higher functions than emotions and pleasure. "For people who use these drugs, they are less an addiction than an intellectual drive to alter mood and produce higher levels of consciousness," he says. "And when we look at how they act in the brain, we can begin to understand why."

The two most common types of tranquilizers, barbiturates and benzodiazepines (Valium and its cousins), also act differently in the brain. They don't have their own receptors, but act on a "foster" receptor, GABA, which is predominantly an inhibitory, or slow-down, neurotransmitter. These drugs "deinhibit" and, in sort of a double-negative effect, increase inhibition, sedating the user. "What these drugs do is hyperactivate inhibition," notes Childers. "Increase GABA enough and you shut down the brain. That's what sedatives do." Alcohol also appears to act on GABA receptors, amphetamines interrupt dopamine balance, and nicotine stimulates the release of endorphins, at least at high doses.



Originally published by Psychology Today:Sep/Oct 94









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All or Nothing: The Extremes of Alcoholism

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All or Nothing: The Extremes of Alcoholism

Provided by Psychology Today

American attitudes toward alcohol are paradoxical: we focus almost exclusively on abstinence, yet we frequently drink to excess. Every year $2 billion is spent advertising and promoting alcohol's intoxicating nature at the same time $10 billion is used to treat people who can't handle their liquor.

Still, Americans are drinking less these days--it's just that we're drinking worse. Individual consumption has declined 20 percent since 1980--from a high of 8.2 liters to a low of 6.6 liters in 1994. But the number of alcoholics and alcohol abusers--problem drinkers who don't go through withdrawal with abstinence but who do have social, legal, and/or family problems as a result of their drinking--hasn't decreased.

THE YOUNG AND THE EXCESS

Indeed, indications are that problem drinking is on the rise, especially among the young. And Americans coming of age today seem to be drinking more excessively than previous generations.

o When over 17,500 college students were surveyed by social psychologist Henry Wechsler, Ph.D., and colleagues at the Harvard School of Public Health in 1993, 44 percent said they'd engaged in what Wechsler characterized as binge drinking during the prior two weeks. For men, this meant five or more drinks in a row; for women, four or more.

o The National Institute of Mental Health's 1991 Epidemiological Catchment Area (ECA) study intensively examined emotional and behavioral problems in five areas of the United States in the late 1980s. When it came to the prevalence of alcoholism and alcohol abuse, John Helzer, M.D., of the University of Vermont, and his colleagues found that 27 percent of men age 18 to 29 either had abused alcohol or were alcoholics at some point in their lives, compared with 21 percent of men age 45 to 64, and only 14 percent of men age 65 and up.

o A recent report issued by Columbia University's Center on Addiction and Substance Abuse claims that women age 18 to 29 are now drinking almost as much as men. However, the ECA figure for lifetime abuse for women age 18 to 29 is 7 percent.

THE IMPETUS FOR ABSTINENCE

This increase becomes even more startling when you consider this country's draconian drinking policies. The United States is the only Western country that restricts the purchase and public consumption of alcohol to adults age 21 and older. Countries as diverse as Switzerland, Britain, and Austria permit 16-year-olds to buy alcohol and/or drink in public, though many do require that parents accompany quaffing kids.

In Portugal and Belgium, there are no age restrictions on purchasing or drinking alcohol, and in New Zealand, children of all ages can drink in public with their parents.

These countries believe that kids who are allowed to drink with their families become socialized to drinking moderately. In the United States, despite--or perhaps because of--continual admonitions not to drink, the young and inexperienced often go overboard.

Of course, our all-or-nothing approach to alcohol is rooted in America's tradition of temperance. But our obsession with inebriants didn't disappear with the repeal of Prohibition in 1933. In fact, when Alcoholics Anonymous (AA) was founded in 1935, its credo, like that of the private alcohol sanatoriums of the day, was abstinence. Then as now, AA saw alcoholics as "out of control," with treatments usually consisting of lectures and group confrontation sessions. Drinkers never fully overcome their problem; instead they are perpetually in recovery.

AA and its 12-step philosophy now dominate the entire U.S. alcohol-treatment system, especially 28-day private hospital programs. This system, which is predicated on the notion that alcoholism is a disease, that cravings are inbred and cannot be modified, and that eliminating alcohol is the goal of treatment, appeals to something deeply American: our fear of alcohol and its power, and our almost fundamentalist moralism about liquor. What better than the edification of an individual by public confession and contrition?

The linking of nineteenth-century revivalistic Protestantism to alcohol problems has been a marketer's dream. In our minds, a connection has now taken hold that runs so deep it can never be broken, despite the fact that new ways of approaching alcohol treatment have been suggested for more than a quarter century.

In 1990, for example, the prestigious National Academy of Sciences' Institute of Medicine (IOM) convened a blue-ribbon panel on alcohol problems. The IOM's primary recommendation was to diversify the kinds of treatments available for alcohol problems. In particular, it found that most drinking problems are not serious enough to justify America's intensive, one-size-fits-all hospital treatment programs.

But there's barely been a shift in the way problem drinkers are treated, except for one significant change in treatment setting.

In 1986, University of New Mexico psychologists William Miller, Ph.D., and Reid Hester, Ph.D., reviewed all research comparing the results of intensive hospital treatment with those of less-intensive alternatives. They determined that both were equally successful. The few differences that were found favored the less-intensive treatments.

In part because of findings like Miller and Hester's--but also owing to pressures to reduce health-care costs--90 percent of U.S. alcohol treatment now occurs in outpatient settings. These programs remain geared towards AA, however, with abstinence the sole goal of treatment.

QUITTING IN OTHER COUNTRIES

The hospital programs that predominate in America are practically nonexistent in Britain, Canada, and other Western countries. In these countries, treatment is more often community-based, dealing with the alcoholic/abuser in his or her life context.

In his 1995 book, Liberating Solutions to Alcohol Problems, British physician Douglas Cameron, M.D., describes a community-based alcohol program he's involved in that's been operating in Britain for the last two decades. This program doesn't require people to stop drinking, no matter how severe their problem. Instead, participants report to an Alcohol Advice Clinic which helps them find the resources necessary to deal with any of a host of problems they may have. For instance, a man who wet his bed after heavy drinking bouts was advised to wake himself during the night by setting an alarm clock.

Obviously other problems require more serious therapy. But it's not what you might think. A man who consistently fought with his family after drinking was counseled about how to lessen family conflict, not how to quit drinking. What often happens, however, is that following this kind of intervention, people do decide to cut back.

Reduced drinking goals are recommended to those who feel their drinking is excessive--including those who would be considered alcoholics in the United States. While some of the people who enter this program do choose to abstain, they must propose this goal themselves. But abstinence is not a lifetime requirement. This program is based on the idea that when people acquire the personal resources they need to gain some control of their lives, they can then gain control of their drinking.

A NATURAL WAY TO RECOVER?

Investing power in the individual and not the treatment enables people to rethink their drinking problem on their own, what's known as self-cure or natural remission.

Studies of alcohol abusers in community settings show that they frequently outgrow their drinking problems on their own. Psychiatrist George Vaillant, M.D., was part of a Harvard study that followed a group of men for four decades, beginning in adolescence. In his 1983 book The Natural History of Alcoholism, Dr. Vaillant reported that over 60 percent of those who overcame their alcoholism didn't enter any kind of treatment, including AA.

Later in the decade, research by Kaye Fillmore, Ph.D., of the University of California, San Francisco, found that between 60 and 80 percent of problem drinkers stopped abusing alcohol, usually without treatment.

Canadian addiction research investigators Linda Sobell, Ph.D., John A. Cunningham, Ph.D., and Mark Sobell, Ph.D., recently reported that more than three-quarters of the randomly selected adults they looked at from two independent studies had recovered from alcohol problems, for a year or more, without formal help or treatment.

According to Helzer and the ECA study, over half of all problem drinkers who stop abusing alcohol do so within five years of the start of their problem--usually by reducing their drinking, not quitting altogether.

America's alcohol-treatment industry attacks the idea of self-cure, saying people who believe they've recovered on their own are in denial.

NEW APPROACHES THAT WORK

Newer treatment approaches see a person's ability to change primarily as a matter of personal commitment and community support. It's believed that people must choose their own consumption goals because they will sabotage any medical recommendation they don't accept.

Indeed, we're more likely to adhere to treatment goals that we participate in setting. For example, British psychologists Jim Orford, Ph.D., Nick Heather, Ph.D., and Guliz Elal-Lawrence, Ph.D., have found that alcoholics succeed better at either controlled drinking or abstinence when they believe they will succeed at one of these two goals.

In order to increase the likelihood for change, alcohol treatment must appeal to a person's own values. Three methods providing this perspective have been found to be effective:

Brief Interventions do not view patients as out of control. They avoid classifying people as alcoholics or problem drinkers. Controlling one's drinking is the person's responsibility. A primary care physician or other health care worker first assesses whether someone is drinking excessively. The care worker then provides feedback about normal levels of drinking and the likely health outcomes from excessive drinking. In some cases, liver function test results are presented. Patient and doctor then agree on a reduced-drinking goal. Brief interventions work best when they are integrated into ordinary health care so that the person's success is assessed at regular follow-up visits.

In the 1990s, a number of tests, including international trials conducted for the World Health Organizations that were published last summer, found that brief interventions helped many people succeed in reducing their drinking.

Motivational Enhancement fosters people's own motivation to change. Therapists are careful not to confront alcoholics, but rather explore and accept their views of their own drinking. Therapists encourage drinkers to compare the consequences of their drinking with their core values. When the gap is sufficiently great, drinkers usually develop their own impetus to change.

Social Skills Training teaches the skills necessary to avoid drinking situations; to cope with stressful settings; and to deal with spouses, children, bosses, and other relationships. These include learning how to manage anger, how to relax, how to reverse negative thinking, how to be assertive and express needs constructively, and how to give criticism and accept feedback.

In their 1995 Handbook of Alcoholism Treatment Approaches, Miller and colleagues performed a meta-analysis ranking all current alcoholism treatments. They rated only studies that had randomly assigned alcoholics to at least one comparison group in addition to the treatment being evaluated. A total of 219 studies met the criteria.

Forty-three treatments were ranked, although 13 of them had too few studies to be definitively rated. Brief interventions had the highest score, followed by social skills training. At the bottom of the list in effectiveness were general alcoholism counseling and educational lectures and films about alcoholism. AA received the lowest score among the 13 treatments inadequately tested. Miller et al. were quick to note that the treatments with the worst clinical records are almost universally the ones used by American alcoholism programs.

Matching People to Treatment

Research has consistently shown that people who are married, hold down jobs, and in general have stable lives have by far the best chance for overcoming alcohol problems. In other words, these individuals will succeed best on average no matter which treatment they receive. Other factors that contribute to the success of treatment are a person's social skills and motivation to change. Though people vary in their abilities, those with different traits may simply respond better to different types of treatment. Moreover, Orford and Heather have shown that people's response to treatment depends more on how they think about themselves than on the severity of their actual symptoms. For example, people who believe they can drink moderately are more likely to actually succeed at controlling their drinking, contrary to AA's denial theory.

Other research has compared the success of treatment with the person's views of whether alcoholism is a disease. Heather and his co-worker Stephen Rollnick, Ph.D., found that hospitalized alcoholics who believed alcoholism was a disease were more likely to drink excessively after having a single drink than those who didn't believe their alcoholism was a disease, thus making moderate drinking harder for them.

Miller and colleagues found that problem drinkers who didn't see their alcoholism as a disease did better with therapists who allowed them to reflect on the effects of their drinking rather than accusing them of being alcoholic. However, they found that even those who viewed alcoholism as a disease didn't do better with the confrontational 12-step approach.

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) created an elaborate $12 million research project, called Project MATCH, to test the notion that alcoholics will do better when they are assigned to a treatment appropriate to them and their drinking problem. Three treatments were tested: 12-step, cognitive-behavioral coping skills (this includes social skills training), and motivational enhancement. Each client was tested extensively and randomly assigned to one type of treatment. The hypothesis was that people's distinct profiles would predict the therapy that worked best for them.

Results of the study are now in: no treatment did better than any other; no set of traits predicted which therapy worked best for a person. However, this trial may have fallen prey to the Hawthorne effect: people given special attention--and the very best therapy programs--progress uniformly well. But was the 12-step therapy in this trial comparable to the typical treatment offered at hospitals?

Trying to put the best light on the results at the recent 1996 Joint Scientific Meeting of the Research Society on Alcoholism and the International Society for Biomedical Research on Alcoholism, NIAAA director Enoch Gordis, M.D., pointed to the number of people who succeeded with each treatment as proof that alcoholism therapy in general works. Observers immediately countered that the study didn't include a control group that didn't receive any treatment. No one can say that a group of people selected for special attention would not have done as well with any therapy or with no therapy

Project MATCH did not support the idea that a scientific assessment can do better than individuals can do for themselves in selecting the right treatment. Despite elaborate reprove that programs can be scientifically matched to problem drinkers, the evidence indicates that people do best when they select the type of treatment they feel will work best for them and when they can pick the goal they believe they can best reach. Science will tell us no more.

Obviously, no one treatment is universally successful. Unlike the treatment for pneumonia or insulin-dependent diabetes, there's no single practice that works equally well for all people with alcohol problems. The safest conclusion, then, is that a wider array of treatments needs to be made available in America.

By: Stanton Peele
Originally published by Psychology Today:Sep/Oct 96










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Addiction - A Whole New View

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Addiction - A Whole New View

Provided by Psychology Today

Our addiction theories and policies are woefully outdated. Researchshows that there are no demon drugs. Nor are addicts innately defective. Nature has supplies us all with the ability to become hooked--and we all engage in addictive behaviors to some degree.

Millions of Americans are apparently "hooked," not only on heroin, morphine, amphetamines, tranquilizers, and cocaine, but also nicotine, caffeine, sugar, steroids, work, theft, gambling, exercise, and even love and sex. The War on Drugs alone is older than the century. In the early 1990s, the United States spent $45 billion waging it, with no end in sight, despite every kind of addiction treatment from psychosurgery, psychoanalysis, psychedelics, and self-help to acupuncture, group confrontation, family therapy, hypnosis, meditation, education and tough love.

There seems no end to our "dependencies," their bewildering intractability, the glib explanations for their causes and even more glib "solutions."

The news, however, is that brain, mind, and behavior specialists are re-thinking the whole notion of addiction. With help from neuroscience, molecular biology, pharmacology, psychology, and genetics, they're challenging their own hard-core assumptions and popular "certainties" and finding surprisingly common characteristics among addictions.

They're using new imaging techniques to see how addiction looks and feels and where cravings "live" in the brain and mind. They're concluding that things are far from hopeless and they are rapidly replacing conjecture with facts.

For example, scientists have learned that every animal, from the ancient hagfish to reptiles, rodents, and humans, share the same basic pleasure and "reward" circuits in the brain, circuits that all turn on when in contact with addictive substances or during pleasurable acts such as eating or orgasm. One conclusion from this evidence is that addictive behaviors are normal, a natural part of our "wiring." If they weren't, or if they were rare, nature would not have let the capacity to be addicted evolve, survive, and stick around in every living creature.

"Everyone engages in addictive behaviors to some extent because such things as eating, drinking, and sex are essential to survival and highly reinforcing," says G. Alan Marlatt, Ph.D., director of the Addictive Behaviors Research Center at the University of Washington. "We get immediate gratification from them and find them very hard to give up, indeed. That's a pretty good definition of addiction."

"The inescapable fact is that nature gave us the ability to become hooked because the brain has dearly evolved a reward system, just as it has a pain system," says physiologist and pharmacologist Steven Childers, Ph.D., of Bowman Gray School of Medicine in North Carolina. "The fact that some things may accidentally or inadvertently trigger that system is somewhat beside the point.

"Our brains didn't develop opiate receptors to tempt us with heroin addiction. The coca plant didn't develop cocaine to produce what we call crack addicts. This plant doesn't care two hoots about our brain. But heroin and cocaine addiction certainly tell us a great deal about how brains work. And how they work is that if you taste or experience something that you like, that feels good, you're reinforced to do that again. Basic drives, for food, sex, and pleasure, activate reward centers in the brain. They're part of human nature."

NEW THINKING, OLD PROBLEM

What we now call "addictions," in this sense, Childers says, are cases of a good and useful phenomenon taken hostage, with terrible social and medical consequences. Moreover, that insight is leading to the identification of specific areas of the brain that link feelings and behavior to reward circuits. "In the case of addictive drugs, we know that areas of the brain involved in memory and learning and with the most ancient part of our brain, the emotional brain, are the most interesting. I'm very optimistic that we will be able to develop new strategies for preventing and treating addictions."

The new concept of addiction is in sharp contrast to the conventional, frustrating, and some would say cynical view that everything causes addiction.

Ask 10 Americans what addiction is and what causes it and you might get at least 10 answers. Some will insist addiction is a failure of morality or a spiritual weakness, a sin and a crime by people who won't take responsibility for their behavior. If addicts want to self-destruct, let them. It's their fault; they choose to abuse.

For the teetotaler and politicians, it's a self-control problem; for sociologists, poverty; for educators, ignorance. Ask some psychiatrists or psychologists and you're told that personality traits, temperament, and "character" are at the root of addictive "personalities." Social-learning and cognitive-behavior theorists will tell you it's a case of conditioned response and intended or unintended reinforcement of inappropriate behaviors. The biologically oriented will say it's all in the genes and heredity; anthropologists that it's culturally determined. And Dan Quayle will blame it on the breakdown of family values.

The most popular "theory," however, is that addictive behaviors are diseases. In this view, an addict, like a cancer patient or a diabetic, either has it or does not have it. Popularized by Alcoholics Anonymous, the disease theory holds that addictions are irreversible, constitutional, and altogether abnormal and that the only appropriate treatment is total avoidance of the alcohol or other substance, lifelong abstinence, and constant vigilance.

ABSOLVING THE DISEASED

The problem with all of these theories and models is that they lead to control measures doomed to failure by mixing up the process of addiction with its impact. Worse, from the scientific standpoint, they don't hold up to the tests of observation, time, and consistent utility. They don't explain much and they don't account for a lot. For example:

o Not all drugs of abuse create dependence. LSD and other hallucinogens, caffeine, and tranquilizers are examples. Rats, for example, which can be easily addicted to heroin and cocaine just like humans, "just can't appreciate a psychedelic experience," notes Childers. "The same is true of marijuana and caffeine; it's hard to get animals to take them. People take these drugs for different reasons, not to feel pleasure."

At the same time, rats and other animals can become physically dependent on alcohol, but won't seek out alcohol even when they are in convulsions of withdrawal. Says Jack Henningfield, Ph.D., an addiction researcher at the National Institute of Drug Abuse in Baltimore, "we can get rats physically dependent on alcohol and even get them to go through DTs by withdrawing them. But we can't get them to crave alcohol naturally." Apparently, they have to learn, to be taught to want it. "Only when we give them the rat equivalent of smoke-filled rooms, soft jazz, and other rewards will they seek out alcohol."

o Some substances with dearly addictive properties are almost universally used and socially acceptable. Giving up coffee and colas containing caffeine can yield rapid heart beats, sweating, irritability, and headaches--markers of withdrawal.

o People can experience withdrawal syndromes with drugs that don't addict them or make them physically or psychologically dependent. Postsurgical morphine is always withdrawn gradually in the hospital, but most people who get morphine still undergo so-called white flu--flu-like symptoms after they leave the hospital. They are actually undergoing withdrawal symptoms, but they have not become dependent on or addicted to the morphine. There is also no evidence that terminal cancer patients in severe pain get "high" on heavy doses of morphine, although they do become dependent.

o Some drugs of abuse produce tolerance and some don't. Heroin addicts need more and more of it to avoid withdrawal symptoms. Cocaine produces no tolerance, yet most would say cocaine is far more addictive because craving accelerates to sometimes lethal doses. If permitted, lab rats will continue to take cocaine until they die.

o Some people, notably celebrities, check in regularly at the Betty Ford Center to overcome addiction to painkillers, alcohol, and barbiturates. Yet one of the most famous studies on Vietnam veterans shows that very few of those who returned addicted to heroin stayed addicted. Lots of planning went on for intensive treatment for them. But on follow-up back home, their rate of continuing addiction dropped to levels no different than those of the general population, despite their exposure to lots of drugs, stress, high-risk environments, youth, and other risk factors that predicted a serious addiction epidemic. They had no trouble for the most part leaving their addictions behind in the jungles, while in the U.S., relapses are legendary and widespread.

For decades, we've sent heroin addicts to Lexington, Kentucky, for treatment in an isolated treatment facility; the idea was to remove them for long periods from their conducive environments. Almost all got "clean" and stayed that way, but when released, still sought out their old haunts and relapsed. Yet the majority of people living in drug-infested cultures never get addicted.

o The children of alcoholics have a much higher risk of alcohol abuse than children of nonalcoholics. Some studies show that alcoholics have an enzyme abnormality related to alcohol activity that doesn't seem to exist in people who've never had a drink. Yet some people who are classic alcoholics can and do learn to drink moderately and safely. Others quit even when they know they can drink moderately.

DEBUNKING THE DOMINO THEORY

"I began to understand the bankruptcy of many addiction theories when a lot of my predictions about alcoholism and treatment for it were dead wrong," says William R. Miller, Ph.D. A professor of psychology and psychiatry and director of the Center on Alcoholism, Substance Abuse, and Addictions at the University of New Mexico, his controversial studies of "controlled drinking" in the early 1970s were among the first to dash with the "disease" theory of addictions.

"I developed a reasonably successful program that taught alcoholics how to drink moderately. Lots of them eventually totally quit and became abstainers. I would never have predicted that. The prevalent theories were that they would either eventually relapse and lose control of their drinking or that they would quit because moderation did not work. We knew from blood and urine tests that they were able to moderate but quit anyhow. The old domino theory that one drink equals a drunk proved, for some, to be baloney. We know with cigarette smoking and alcohol and other addictive behaviors that moderation, tapering, and 'warm turkey' can be very effective." Miller blames mostly the persistent strength of the addiction-as-disease concept on the peculiarly American experience with alcohol and Prohibition.

"During Prohibition, alcohol was marked as completely dangerous and the message was that no one could use it safely. At the end of Prohibition, we had a problem: a cognitive dissonance. Clearly many people could use it safely, so we needed a new model to make drinking permissible again. That led to the idea that only 'some' people can't handle it, those who have a disease called alcoholism."

Everyone likes this model, Miller says. People with alcohol problems like it because they get special status as victims of a disease and get treatment. Nonalcoholics like it because they can tell themselves they don't need to worry if they don't have the "disease." The treatment industry loves it because there's money to be made, and the liquor industry loves it because under this theory, it's not alcohol that's the problem but the alcoholic.

"What's really bizarre," says Miller, "is that the alcohol beverage industry spends a lot of money to help teach us about the disease model. It's the inverse of the temperance movement, which many now laugh at, but which saw alcohol more realistically as a dangerous drug. It is."

Today, Miller notes, heroin and cocaine are looked upon the way the temperance movement once looked on alcohol. "Ironically, too," he says, "we are treating nicotine and gluttony the way we once treated alcohol. It's easy to see how the disease model and all other single-cause theories of addiction can lead to blind alleys and bad treatments in which therapists adopt every fad and reach into a bulging bag of tricks for whatever is in hand or intuitively meets the immediate moment. But what we wind up with are three myths about alcoholism and other addictions: that nothing works, that one particular approach is superior to all others, and that everything works about equally well. That's nonsense."

NO EASY TARGETS

"The most likely truth about addiction is that it's not a single, basic mechanism, but several problems we label 'addiction,'" says Michael F. Cataldo, Ph.D., chief of behavioral psychology at Johns Hopkins Medical Institutes. "No one thing explains addiction," echoes Miller. "There are things about individuals, about the environment in which they live, and about the substances involved that must be factored in." Experts today prefer the term "addictive behaviors," rather than addiction, to underscore their belief that while everyone has the capacity for addiction, it's what people do that should drive treatment.

So while all addictions display common properties, the proportions of those factors vary widely. And certainly not all addictions have the same effect on the quality of our lives or capacity to be dangerous. Everyday bad habits, compulsions, dependencies, and cravings dearly have something in common with heroin and cocaine addiction, in terms of their mechanisms and triggers. But what about people who are Type A personalities; who eat chocolate every day; who, like Microsoft's Bill Gates, focus almost pathologically on work; who feel compelled to expose themselves in public, seek thrills like racecar driving and fire fighting, or obsess constantly over hand washing, hair twirling, or playing video games. They have--from the standpoint of what their behavior actually means to themselves and others--very little in common with heroin and crack addicts.

Or consider two of the more fascinating candidates for addiction--sex and love. Anthropologist Helen Fisher, Ph.D., of the American Museum of Natural History, suggests that the initial rush of arousal and romantic, erotic love, the "chemistry" that hooks a couple to each other, produces effects in the brain parallel to what happens when a brain is exposed to morphine or amphetamines.

In the case of love, the reactions involve chemicals such as endorphins, the brain's own opiates, and oxytocin and vasopressin, naturally occurring hormones linked to male and female bonding. After a while, though, this effect diminishes as the brain's receptor sites for these chemicals become overloaded and thus desensitized. Tolerance occurs; attachment wanes and sets up the mind for separation, so that the "addicted" man or woman is ready to pursue the high elsewhere. In this scenario, divorce or adultery becomes the equivalent of drug-seeking behavior, addicts craving for the high. According to Fisher, the fact that most people stay married is "a triumph of culture over nature," much the way, perhaps, nonaddiction is.

Experts generally agree on the most common characteristics of addictions that trouble society:

o The substance or activity that triggers them must initially cause feelings of pleasure and changes in emotion or mood.

o The body develops a physical tolerance to the substance or activity so that addicts must take ever-larger amounts to get the same effects.

o Removal of the drug or activity causes painful withdrawal symptoms.

o Quite apart from physical tolerance, addiction involves physical and psychological dependence associated with craving that is independent of the need to avoid the pain of withdrawal.

o Addiction always causes changes in the brain and mind. These include physiological changes, chemical changes, anatomical changes, and behavioral changes.

o Addiction requires a prior experience with a substance or behavior. The first contact with the substance or activity is an initiation that may or may not lead to addiction, but must occur in order to set in motion the effects in the brain that are likely to encourage a person to try that experience again.

o Addictions cause repeated behavioral problems, take a lot of a person's time and energy, are openly sanctioned by the community, and are marked by a gradual obsession with the drug or behavior.

o Addictions develop their own motivations. For addicts, their tolerance and dependence in and of themselves become reinforcing and rewarding, independent of their actual use of the drug or the "high" they may get. "One way of understanding this," says Cataldo, "is to analyze what is happening behaviorally in withdrawal. Given that withdrawal is so punishing, why do addicts let themselves go through it more than once? One answer is that the withdrawal, when combined with relapse and returning to the use of the substance, itself may be 'rewarding.'"

HAIR OF THE DOG

The withdrawal and relapse cycle suggests that like any behavior, the addict "gets something out of" the pain of withdrawal--attention, perhaps, or help. But, in any case, enough so that he not only is willing to do it again, but also may seek out the cycle the way he once sought out the drug.

In gambling addictions and certain eating disorders, particularly, says Toni Farrenkopf, Ph.D., a Seattle psychologist, the "rush" for the addict often comes from pursuit of the activity after "getting clean and clear" for a while, along with eluding police, spouses, parents, bill collectors, and employers.

"We know this is the case with animals we can train to do something, even if they never get a positive reward out of it," Cataldo says. The "reward" is escape from or absence of an electric shock or punishment, even if it's only occasional escape or unpredictable escape. The cocaine addict may be addicted to the pursuit of cocaine and stealing to get money to buy the drug; using coke may be secondary to the reward of not getting caught and the "high" of pursuing the drug life-style.

If addictions have characteristics in common, so do addicts, the experts say.

They have particular vulnerabilities or susceptibilities, opportunity to have contact with the substance or activity that will addict them, and a risk of relapse no matter how successfully they are treated. They tend to be risk takers and thrill seekers and expect to have a positive reaction to their substance of abuse before they use it.

Addicts have distinct preferences for one substance over another and for how they use the substance of abuse. They have problems with self-regulation and impulse control, tend to use drugs as a substitute for coping strategies in dealing with both stress and their everyday lives in general, and don't seek "escape" so much as a way to manage their lives. Finally, addicts tend to have higher-than-normal capacity for such drugs. Alcoholics, for example, often can drink friends "under the table" and appear somewhat normal, even drive (not safely) on doses of alcohol that would put most people to sleep or kill them.

The biological, psychological, and social process by which addictions occur also have common pathways, but with complicated loops and detours. All addictions appear now to have roots in genetic susceptibilities and biological traits. But like all human and animal behaviors, including eating, sleeping, and learning, addictive behavior takes a lot of handling. The end product is a bit like Mozart's talent: If he'd never come in contact with a piano or with music, it's unlikely he would have expressed his musical gifts.

Floyd E. Bloom, M.D., chairman of neuropharmacology at the Scripps Clinical and Research Foundation in La Jolla, California, once gave a talk called "The Bane of Pain Is Mainly in the Brain." His point was that both pain and pain relief occur in the brain, triggered by the release, control, uptake, and quantity of assorted brain chemicals and other natural substances. The same might be said for addiction. Regardless of the source of addiction, the effects are "mainly in the brain," physically, chemically, and psychologically affecting emotions and energy levels.

The new view of addiction ties together biology, chemistry, behavior, and emotions in the brain. Among others, Edythe London, Ph.D., chief of neuroimaging and the drug-action section of NIDA, has conducted experiments demonstrating that such links are in fact formed and offering some clues as to how that happens.

In her work, the first of its kind funded by the Office of National Drug Control Policy, she is using positron emission tomographic (PET) scans to figure out how drugs and behaviors produce the rewards that create addicts and keep them addicted even when the euphoria ends, the tolerance builds, and the withdrawals occur. She is homing in on areas of the brain where craving lives both neurochemically and psychologically.

PET scans measure the brain's uptake of glucose, the principal source of energy used by the brain to function, and locate areas of the brain affected by various experiences. By tagging glucose molecules with radioactive and other "tracers," scientist like London can watch the brain react to stimuli such as and work.

In early studies, she and her colleagues gave addictive drugs under carefully controlled conditions to addicts and gauged their mood and feelings while monitoring the rate of glucose use. "The surprising thing we found is that all drugs of abuse--even those that differ radically in structure such as morphine and cocaine--do the same thing. They reduce use of glucose in the brain, so providing a way to observe which areas of the brain are involved in specific psychological effects. The amount of glucose used in certain parts of the brain's cortex, moreover, was closely related to how good people felt, regardless of where any drug binds.

London says this common pathway of reduced brain metabolism should not really have surprised her. "If you think about it, it makes sense," she says, "because glucose is an index of brain activity and brain activity in any given area is a function of not only what drugs are binding right there, but of nerve connections feeding into that area. The final picture of drug action usually looks quite different than the pattern of where a drug binds. That's because the brain is a highly interconnected organ. Clearly, if a drug acts on dopamine-neurotransmitter systems in part of the limbic brain initially, it's easy to see that there would be wider distribution through the brain's networks and that the impact of the drug could be very diffuse and varied."

So far, London and others have seen this reduction in glucose use with morphine, cocaine, nicotine, buprenorphine (a treatment for opiate addicts), amphetamine, benzodiazepine, barbiturates, and alcohol. "All drugs of abuse do this."

From these studies, London moved on to experiments designed to show that an addict's brain is permanently different from what it was before and after the initial exposure. "I wanted to know where craving lived in the brain," she says.

Her first idea was wrong. "I thought that drug addicts had the same kind of situation as people with obsessive-compulsive disorder (OCD) in terms of where the brain was affected," she says, "because all OCD victims, like drug abusers, had a lack of impulse control. Studies had shown that they had disorders of the orbital frontal cortex, the part of the brain near the temple, and that's where I went looking."

She conducted experiments in which she gave a lot of drug-related cues--but not drugs--to cocaine addicts. These cues included videotapes showing crack houses, mounds of white powder, $10 bills, and people "high." "We thought that would make them crave the drug and we'd be able to see glucose use diminish in the orbital frontal cortex."

The bad news was that the orbital frontal cortex showed nothing. The good news was that they got a "pretty dramatic effect" in two other areas of the brain, the amygdala and the hippocampus.

The hippocampus is a bundle of fibers linked to learning and short-term memory and carries signals in and around the limbic system, forming electrochemical junctions for the emotional seat of the brain. The amygdala, located in the lower arc of the limbic system, is the seat of "fight or flight" reactions, and impairment Or injury can lead to profound behavior changes. There is also evidence that the amygdala has a role in recalling pleasant or painful consequences of experiences and damage to this may flatten or remove some of this recall.

London hasn't entirely abandoned her notion that the orbital frontal cortex also is involved in addicts' recall of their drug experience and the onset of craving. Recent research suggests this part of the brain may be the anatomical location of "source memory," the place that helps people remember when and where and how a memory was formed, or whether it is a "real" memory at all.

London says she is convinced that addiction takes place in stages and requires not only initiation to a substance or to an activity that brings great pleasure, physically and/or psychologically, but also creation of nondrug "incentives" to keep using the drug and craving it. The incentives include the creation of memories--via the creation of neural pathways-of the pleasure and good mood and the excitement of getting the drug, preparing it, or sharing it with others.

"What we're talking about is like conditioning," says London. "Over time, events that happen concurrently with the euphoria begin to contribute to the drug experience and are involved in a sensitization process. They too probably produce a biochemical effect in the brain and become very important in the addiction process."

IF THAT HAPPENS, IT GOES A LONG WAY to explaining why relapse rates are so high, even for addicts who are "detoxified" and off drugs for long periods. Even when people clean up their act and stay dean for some time, they are still very vulnerable and this may have something to do not only with receptor sites and neurotransmitters, but also with biochemical processes that produce long-term, stored memories of the drug experience. Says London: "In my view, biochemical and psychological memories act in the same way. What we're talking about is learning at the molecular level--and the reason that addicts, long after they are free of a drug, can experience intense craving when presented with stimuli--even photographs or sounds--that remind them of the drug experience."

If there is a hitch in this new picture of addiction it is that it is far from simple. It is also politically incorrect, unlikely to make the "Just Say No" and "law and order" crowd very happy. But it is putting solid foundations under prevention and treatment programs and promising entirely new strategies to combat drug abuse. The implications of this new view of addiction are in fact profound for treatment, prevention, and public policy.

L.H.R. Drew, an Australian addiction expert, notes that "if the idea prevails that drug use--and more particularly drug addiction--is a special type of behavior which is highly contagious, irreversible, inevitably leads to disease, and is due to the special seductive properties of certain drugs, then our approach to reducing drug problems is not going to change. If, however, the ideas prevail that drug use is more similar than different to other behaviors and that there is little that is special about drug addiction compared with other addictions that are universally experienced, then the drug hysteria may abate and a rational approach to policies to reduce drug problems may be possible. It must be known that people get into trouble with drugs in the same way that they do with many other things...particularly behaviors giving short-term rewards."

In the new view of addiction, says Childers, people vary in their ability to manage problems and pleasures, "but we must recognize that we all share the same circuits of pleasure, rewards, and pain. Anyone who takes cocaine will enjoy it; anyone who has sex will enjoy it. There is nothing abnormal about getting high on cocaine. Everyone will. There is a natural basis of addiction and we need to get away from the concept that only bad or weak or diseased people have problems with addiction. Telling someone to 'just say no' is like telling someone to just say no to eating and drinking and sex. We must begin to see how very human and very hard this is. But it is far from hopeless."


A TRIAL OF PRAYER

With a $30,000 grant from the National Institutes of Health's Office of Alternative Medicine, Scott Walker, M.D., is embarking on a study of prayer against substance abuse. It's not that alcoholics do the praying. Outsiders totally unknown to them will pray on their behalf.

Walker says his interest in the potential healing effects of intercessory prayer was triggered by his own strong spiritual beliefs.

There are more than 130 trials of "spiritual healing." Daniel J. Benor, M.D., reports in his 1993 book Healing Research, that 56 of the trials show "statistically significant results."

"Even if a therapist is atheistic, the majority of Americans have some spiritual or religious belief. If your patients believe, you need to address this faith factor if there is any chance it can help them," Walker says.

In the one-year study he is conducting, Walker will work with 40 adults about to enter a treatment program with a clinically verified substance abuse problem. At random, half the group will receive outside prayer, the other half will not.

All subjects will have urine drug screens and careful analysis of such factors as their treatment expectations, religious behavior, membership in support groups, and to what degree they are contemplating sobriety, are relapsed, and so on.

Walker is recruiting the pray-ers from the Albuquerque Faith Initiative. The group will include pray-ers of many religions.

They will get a specific suggestion about content: Thy Will Be Done. But they can improvise and must keep time sheets about content, duration and location of sessions.

Walker will not reveal to any of the pray-ers or churches which or whose prayers did anything, if in fact that happens.

"We must absolutely minimize the possibility of any group saying it has a direct link to God."

By: Rodgers, Joann Ellison * * * *
Originally published by Psychology Today:Sep/Oct 94










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